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Thursday, June 05, 2014

EHR Exceptionalism Debunked: Care Quality Variances Among VA Hospitals, Perhaps The Most Wired Hospitals in the World, Suggest the True Value of Information Technology in Healthcare Has Been Grossly Exaggerated

The Wall Street Journal somehow managed to get access to internal VA patient care quality data and published the following article:

Veterans Affairs Hospitals Vary Widely in Patient CareInternal Records Show Facilities Such as Phoenix Have Far Higher Death Rates Than Peers
Thomas M. Burton and Damian Paletta
June 3, 2014

The Phoenix facility at the heart of the crisis at the Department of Veterans Affairs is among a number of VA hospitals that show significantly higher rates of mortality and dangerous infections than the agency's top-tier hospitals, internal records show.

The criticism that precipitated last week's resignation of VA Secretary Eric Shinseki has focused largely on excessive wait times for appointments across the VA's 150-hospital medical system.

But a detailed tabulation of outcomes at a dozen VA hospitals made available to The Wall Street Journal illustrates a deeper challenge: vastly disparate treatment results and what some VA doctors contend is the slippage of quality in recent years at some VA facilities.

Some of the discrepancies are stark, especially for an agency known for offering high-quality care in 50 states.

Yet, these are highly wired hospitals, perhaps the most highly wired in the
world, with one EHR, VistA CPRS, allegedly among the best EHRs in the world developed over decades, and allegedly
used by 100% of the clinicians.

How can this be?

... Scott McRoberts, spokesman for the Phoenix VA Health Care System, said on Monday the database "is an internal measurement system to benchmark our improvement, and is not for public consumption."

The rate of potentially lethal bloodstream infections from central-intravenous lines was more than 11 times as high among patients at the Phoenix facility than it was at top VA hospitals, data from the year ended March 31, 2014, show.

... The findings come from a nonpublic VA database called Strategic Analytics for Improvement and Learning, known as SAIL. SAIL tracks procedure outcomes and ranks VA hospitals on a scale of five stars, the best, to one star, the lowest.

... In other examples of variations in care, the Atlanta VA Medical Center, a two-star hospital for quality, has more than three times the rate of central-IV infections than the average of five-star VA hospitals. Houston's VA hospital, ranked as a two-star hospital, had a 47% higher acute-care mortality rate than the five-star hospital rate.

... EHRs will improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers.

There is no doubt expressed there.

The industry itself has convinced the Federal Government to spend tens of billions of taxpayer dollars on this technology via HITECH incentives, and to start penalizing non-adopters via Medicare cuts. The Government has bought into the hyper-enthusiasm hook, line and sinker, when the same money might have been spent elsewhere such as on care of the underserved...or on our Veterans.

Yet the data from a highly-computerized organization like the VA show that these systems cannot be all they are made out to be. They do not automatically "improve caregivers' decisions and patients' outcomes." This is an on its face observation.

They are simply a tool, and in absence of appropriate human staffing, expertise, and conducive work environment, they mean significantly "less than advertised" in terms of improving care quality and outcomes.

Finally, as the VA has gotten busier due to factors such as the return of veterans from recent wars, one must also ask if the loss of productivity, cognitive burden, and other factors caused by needing to interact with a computer rather than paper has made the computer systems more of an impediment to good care rather than a facilitating tool.

I think it's time the Government start to reform the
industry hype surrounding this technology with far more sober
predictions that would facilitate far more cautious implementations.

No "revolutions" are happening soon, at least not due to information technology in healthcare.

Finally, note that EHR oversell and exceptionalism has been going on for decades. Donald A. B. Lindberg M.D. (http://www.nlm.nih.gov/od/roster/lindberg.html), Medical Informatics pioneer and Director of the U.S. National Library of Medicine at NIH, observed in 1969 that:

"The [second] reason for the dearth of significant success of computers in medicine has been the flagrant and consistent "over sell" of capability on the part of manufacturers and computer enthusiasts."

2 comments:

Anonymous
said...

I wonder, after reading the recent JAMIA article on Lawrence Weed, and then listening to his 1971 Grand Rounds https://www.youtube.com/watch?feature=player_embedded&v=qMsPXSMTpFI, whether or not there was a contributing success to the impact of SOAP notes or even the Problem Oriented Medical Record that has been invisible to medical informatics? Perhaps it's simply the case that the venerable academic medical centers successfully implemented EMRs, and those still in use, such as those at Vanderbilt or Regenstrief are solely the result of clinician leadership, yet the true "national" uptake was on the backs of the IT sector? Does it take a clinician to change clinicians?

I wonder, after reading the recent JAMIA article on Lawrence Weed, and then listening to his 1971 Grand Rounds https://www.youtube.com/watch?feature=player_embedded&v=qMsPXSMTpFI, whether or not there was a contributing success to the impact of SOAP notes or even the Problem Oriented Medical Record that has been invisible to medical informatics? Perhaps it's simply the case that the venerable academic medical centers successfully implemented EMRs, and those still in use, such as those at Vanderbilt or Regenstrief are solely the result of clinician leadership, yet the true "national" uptake was on the backs of the IT sector? Does it take a clinician to change clinicians?

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